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Referral and warning signs
When to refer
IMMEDIATE EMERGENCY REFERRAL/TRANSFER to hospital capable of emergency laparotomy, blood transfusion, intensive care for ALL suspected cases.
Red flags
- Sudden cessation of contractions
- Constant severe abdominal pain
- Maternal shock
- Fetal bradycardia/distress or absent FHR
- Loss of station
- Easily palpable fetal parts abdominally
Signs and symptoms
- Sudden, severe, constant abdominal pain.
- Cessation of contractions.
- Vaginal bleeding (slight or massive).
- Maternal shock (tachycardia, hypotension) out of proportion to visible bleeding.
- Fetal distress or absent FHR.
- Loss of station of presenting part.
- Easily palpable fetal parts abdominally.
- Abdominal tenderness/guarding.
- Change in abdominal contour.
Risk factors
- Previous C/S scar (esp. classical).
- Previous uterine surgery (myomectomy).
- Obstructed labour.
- Grand multiparity.
- Improper oxytocic use.
- Obstetric manoeuvres (versions).
- Instrumental delivery.
- Trauma.
Diagnosis
Clinical assessment
High index of suspicion + clinical signs during labour/postpartum (pain, shock, cessation of contractions, fetal distress/death, change in abdo findings).
Investigations
- Primarily clinical diagnosis in emergency.
- Ultrasound (limited utility acutely).
- Confirmation at laparotomy.
Diagnostic criteria
Clinical diagnosis based on signs/symptoms suggesting uterine tear.
Management
Non-pharmacological management
- EMERGENCY: Call for HELP. ABC resuscitation. 2 large IV lines. Rapid IV fluids. Oxygen. Immediate transfer to Operating Theatre.
Pharmacological treatment
- Blood Transfusion: Urgent cross-match, transfuse WB/PRBCs + FFP/platelets as needed.
- Antibiotics: Broad-spectrum IV (Ceftriaxone + Metronidazole).
Monitoring
Continuous maternal vital signs. Monitor blood loss. Prepare for neonatal resuscitation.
Surgical Management
- Laparotomy: Deliver fetus/placenta. Assess rupture. Uterine Repair (if feasible/stable/desired fertility) OR Hysterectomy (often necessary).
Complications
- Maternal: Massive haemorrhage, Shock, DIC, Organ damage (bladder/ureter), Infection/Sepsis, Hysterectomy/Infertility, Death.
- Fetal/Neonatal: Hypoxia/Asphyxia, Brain damage, Stillbirth/Death.
Prevention
- Judicious oxytocic use.
- Partograph monitoring (esp. TOLAC).
- Early management of obstructed labour.
- Planned repeat C/S for high-risk scars.
- Avoid inappropriate manoeuvres.
Patient education
- (Post-event): Explanation, surgery details. Future pregnancy implications (elective C/S needed). Contraception/FP counseling. Emotional support.
Uganda-specific notes
Devastating complication often linked to obstructed labour/previous C/S/oxytocic misuse. High mortality due to delays. Prevention (skilled attendance, partograph) vital.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.4.4